How to Choose an ACL Graft

Christie Auyeung Orthopedic Surgery Leave a Comment

We most often hear about ACL tears as the devastating injury that wipes out our favorite athletes for the season (or even longer). Whether you play sports as a professional or just for fun, an ACL tear is more than enough to keep you off your feet for a while. You’ll most likely need surgery to repair the injury.

During ACL repair surgery, your surgeon will essentially replace your damaged ACL with ligament and tendon tissue. This replacement tissue, called a “graft,” can come from your own tissue (autograft) or from a donor (allograph).

How should you choose an ACL graft? Let’s break down the pros and cons of each type.

1) Patellar Tendon Autograft

The patellar tendon is located at the front of your knee, and connects the patella (kneecap) to your tibia (shin bone).


  • Strength: This graft closely resembles the torn ACL in length. Additionally, the bone ends of the graft can be placed on the bone where the ACL attaches. This “bone-to-bone” healing results in a very strong attachment.
  • Experience: Surgeons have the most experience with this type of graft, since it has historically been used for the longest time.
  • Recovery time: Full recovery is quicker than other grafts, around 5-6 months.


  • Risk of injury: Because a segment of bone is removed from the kneecap, there is a risk of fracturing or tearing at the patella after surgery.

Pain: This is generally the most painful graft. Some patients experience pain when kneeling, even years after surgery.

2) Hamstring Tendon Autograft

The hamstring muscles are located on the back of your thigh. For this graft, two of the tendons in the hamstring muscles are removed, and then bundled together to become a replacement ACL.


  • Less painful: Since the incision to obtain a hamstring graft is smaller, no bone is removed. In general, this is a less painful graft, both immediately after surgery and years after.
  • The incision to harvest the hamstring graft is the same as one used for fixating the new ACL, reducing the number of incisions to be made.


  • Longer recovery: It takes longer for the grafts to become rigid compared to patellar tendon grafts. Return to full physical capacity takes around 6-7 months.
  • Hamstring weakness: Your hamstring may feel weak, strained, or tender during recovery.

3) Donor Tissue Allograft

Allografts are more commonly used by people who do not play sports competitively, because they are not as strong as a patient’s own tissue. If you are not planning to participate in demanding sports, then an allograft may be sufficient for your needs.


  • Shorter operation: Since there is no need to remove a graft, overall time for the operation is shorter.
  • Less painful: Not needing to harvest a graft also means less pain after surgery.
  • Smaller incisions: Fewer incisions are needed, and the required incisions are smaller.
  • If you don’t respond well to an allograft, you can try again with your own tissue in the future.


  • Weaker graft: Donor graft preparation involves freeze-drying, which kills living cells. This decreases the strength of the tissue.
  • Risk of disease transmission: Although grafts are sterilized during preparation, it does not completely eliminate the risk of HIV or hepatitis infection.

4) Synthetic Grafts

Another option is synthetic grafts, made from materials like carbon fiber, Dacron or PTFE. However, synthetic grafts are not used widely. Although they are quick and easy, they are generally quite expensive to obtain. Furthermore, they are usually weaker and offer inferior results compared to grafts from living tissue. They are prone to degrading and surgeons usually advise against them.

So, Which Do I Choose?

Unfortunately, there isn’t a “right” option. For surgeons, many factors go into their recommendation, such as age, activity level, and work demands. Many surgeons also have a preferred type of graft based on their experience. By weighing the pros and cons of each graft type, and discussing with your surgeon, you can decide which type is best for you. Interested in ACL surgery? Contact one of our world-class surgeons and get started today.

Christie is a UChicago grad currently living in the San Francisco Bay Area. In her free time, she enjoys tap dancing, learning to windsurf, and trying new foods.